HomeMy WebLinkAbout1627A 1980A (9) � WORKERS'COMPENSATION DECLARATION : � � �� ��•� '� � �� � �
I hereby affirm that i have a certiflcate of conseN ta self APP A� ��� FOR BUILDING PERMIT
insure,or a certifimfe of Workers'Ccmpensticn Insurance,or
a ce`�ic/ �opy rhe�eof;Sec.3800,lab.C�.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyN6.��-����'/Company �LyL'�-Lt�:-��
� ce�r�fled�opy�s t,e�e6y f��r,�shed. FOR APPLICANT TO FILL IN aoo ess �.z�' �-CJ�=�-=-+a—.� � �� '
, � Cer!ified ropY is ffled with the counry boilding inspeo 6UILDING �'C/" • � r/J / g �,��j
ticn deparimenf. ADDRE55 / /V � � (.` LOCALITY �'�,..�+�-C.-_
�7 NEAREST
� pa+e Applican! C!TY yIU� �Z:P CROSSST. kz*�+z-�
CERTIFlCATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. ASSes50k
COMPENSATION INSURANCE 5'�.ZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
� fihis secrion need not be completed if the permit is for one �•• �p USe ZONE MAP Q,
� hundred dollars($1001 cr less.) TRAR . [:C7 �o e'�OCK LOi NO. •d NO. �� �� �� r
�/1 TEL y� 57ECIAL �
I certify inat in rhe performonce of ihe work for which this OWNER �f �� [_,�I�� NO.� ry CONoIiIONS o
permi!�s issued,I sholl not employ any person in any manner y DISTRIC7 GROUP iYPE FIRE PROCESSED BY u
ADD2E55 � CONST. ZONE
so as to bemme subject ta ihe Workers'Compensotion Laws. � y --�^� � �
I C• E'�_s' � .� .�<u<��� A
Da�e Appllcant CIiY Z�P 5??.TISTICAL CLASSIFiCATION APT. CONDO. �
ARCNITECT OR TEL.
NOTICE TO APPLICANT: If, offer mpkinq this Ceriificate of ENGINEER NO. CLA55 NO. .�f DWELL.UNITS �
Exemption, you should be<ome subjecr to the Workers' pp!
Compensation provisions of!he La6or Code,yau m�st fcrth- qpDeESS SEWER rt^J+P �
wifh comply with such provisions or 'his permit sholl be ` 7�
deemed revoked. CONTRACTOR �s" n ��` NO. cp� BK,� PG, �"/�.i VALIDATION
LICENSED CONiRACTORS DECLARATION " /� ���. .
I hereby afflrm}nat I am li<ensed�nder provisions of Chopter 9 ADDRESS �" �1(/ lLL- NO. VALUATION
(commencing wllh Section 70001 of Dlvislon 3 of ine Business nnd 's�"�� ♦�,ry �i� � yv ��� z-1 6 2,7 A
Professions Cade,and my license Is m full force and effect. ❑rv '�st��/(jBB��Ir CLASS�- $ .d�
n J SG.FT NO.OF �O.OF CHECK fr• e o 0 2 v
LicenseNumber�Lic.Class /J�'/ S:ZE SiORiES FAMItIES O�E
/��� �/�} a �.f'"�/�rl/Q(,�l NEN! � s I e 1 4 H.8 O
Confrqctor�f+���.%/Y •'Jti//.Date��—,z. � �ESCRIPTIONOFWOI2K � e
� P 9 9ui C.�� --'�6�- l✓v�//7n �C'� ADD � I �:��'.��
I am exem t from+he licensin re rements as I om a � ,[
licensed architect or a registered professionol engineer �+ ��T`R ❑O pATE (+ �/ D'� �2�G�-�2
octing i my professionol capacily (Section 7051, ( `� REPAIR �� ��
Business and Professlons Code). 05E OF
FINAL
Ek15TING BLOG. ` � "/C_ DEMO: ❑ BY
Lic.or Reg.No. Dale APP;�AhT 'L,/1/J TE'�..� � � .
OWNER-BUIL�ER DECLARATION iPR:N?1 � �Jy�i.i!� No. �T
I hereby offirm that I om exempt from the Cor.�ractor's License ��� ���/Jr
Law for the foilowing reason(Section 7031.5, Business and A�DRESS `r f� �
Professions Code): pRESENT
❑ � . BU�LDING
I, as owner of the p•operty, or my employees with AODRE55 s'�� �/�.Q��
wages as their sole compensa�ion,will do ihe work and
ihe srructure is not intended or offered for sole!Section LOCnLIiY r:a n n � e '�
7044,Business and Professions Code1. hM10'J'�,NC TEL.
� I.as owner o`the property,am exdusively contracting CONTRACTCR v0. � m � C;�,��j
wlth Ilcensed confroctors to censtrud ahe project(5eo qp7Rc55 i��; -
tion 7044.Business and Prcfessions Code1. 6 � j , „:;(;<�
REQU'RED -OTA:SET3ACK FROM1^� EXIST.
CONSTRUCTION LENDING AGENCY SE7 3ACK YAR� HWY FROP.:NE WIDiH -
I hereby aff�rm rhat�here is a mnstruction lending agency for p�p�e U J.L f:"`�G
Ihe performance of ihe work for ti-hich tnis permll is issued a� �
ISec.3097,Civ C.). SioE
P:
Lender's Nome f �/ (p� !�f
Lender's Address P_C.Fee 5 1 J• J�f �i�Fee •,`�V
I certify ihat I have read'his aoplicafion and stote thar the Iss e Fee ` ��t
�bove informatlan is mrrect.I agree to mmply wi'h oll Counry In;erlgaiior,Fee �
�rdmances and Sfa�e laws�elating*o building cons�ruCion. ?c o�Fee � ����� �
and her by authorize represenicllves cf tnis County to enter
ipcn Ke abeve-menticned pro er� or inspectlon purpcses � � �- " � � '
tv� /� s lj� ����'�'�(' SEE REVERSE FOR EXPLANATORV LANGUAGE �
_natu�e cf pplicc.-f o�%oen' Daie ' �s
n�-�c,tasea . ..�r�..��_�=v...s.vo...a..,....r..m.t...�..-.-,....-,.P...--....,-�..�........��..,�.w�.,.._---•.-.�.....-.,--'. -, •--��..
k �iAPdS YO:A3�Fi@CFaPiF.�,.•.-��,..:,.-f,�` 4�ISI��C7QR'S NOaES�..����.�..-.�...� OVi�NF,R•IIUIiIYER DECLARAT'IOIti
3�`m��G'•••��«..�------_'�e�o I heraby affirm f1ra9 I am exempf irom tne Contractor's
� n a ��pm�A�� Litense Law for the follo�ain reoson. �ec. 70.31.8
��c: I x^.a�.�e:oe3� � ��� 9 (� 7
? � ��a���^��^� — 73usiva�ss and�rofnsin•s Cnde:E9ry caty or courey u�hieh
i 6N� �esPe 1 6da.� GaaSa_�_ . � regu!res a ber»tit tn cortstrude aTSCT�:ttiRhTD'Jf�demolisb,
as re�air arey s.ructure,prior:o its lssuance,also requEres
I �� � j� �-'-`- -t:�e�t5placax8 for sucb aermit to fs'Ie a r.',qued staCesnent
�� ��
�---v - � --j�— tfiar be is tecensed pursuane;n ahe provisinxs of Ehe Con-
mmmensin with Seo-
� � � I I trattor',�LrcerrsvLaw(Cbaprter9J( g
�iJI �--- tlor,700�J cf Ilavfsiur.3 of tlie Business and Profesalosu
��i ' ---.n�—_ _� I�� � I CodeJ or fAaf be rs rxemfiE tberefrom axd tbe basisfar Efie
+;m-�.-�--�-------.--� � � ---- -.--.--�-- � allegzd exe:mfidiox.Ar.y tiioda#on of SQct:ote 7031.5 by
� � N�� �g�€�'^� p� p,�._��_a�ye,� i � unyaf,+filicantjorapernaedsw8jec3stheapplecanttaacevil
FG" ���-I or&' ��:�� ferw(n+:o,/Rax mrs>e Eb¢x fix�e hwndred rlolkrs($50/J).J:
�� �(r- F.°cs ��°' s . ' , _
^— ___�—� ` 1,as owmer of ehe property,or my employees with
!41'a:er:eniticcte � I wages ns their sole compensation,will do ihe work,and
� f-.—.-� _��._._�__._,-1____ _� . 'he siructure is noP iMended or offered for sols(Set.7044}
`'rlso!th Deparinanr � I I � - CfusiY✓ss and Professio:zs Cr.de:TFia Cnn#ractor's Lfcessse
—�____._.l.._._.-..�1��.�_�_� Law do3a-rsa:apply 4a¢n om^ser jprnper�u wF.o builds
re Deparimenl � � ��'---' — o-arn�roves±�es•eo�a,end u�h.a r/oessucb surk hi:zu�df or
� �' �— • tFisough bis nwn ernployees, firae�rw'ad ESat aucb {m-
Gradino jI I i prna�er?aenls cre xaat Int¢�zded or r.ffer¢d for saiz. If,
-_._l�_.e� ___�J bou�e.zr,lbaSu;idingorlm,9rc�enrenPissoldwitEinone
aloyical � 1"�-' . . 1�ear o£campl¢econ, tne nwsaenbue.'der wilb bave th_¢
�,-�'--�_I,_ � . bur�de?a cf,�rar�dsag¢cat 5e did reo6 hsstld�r irnporovs jor
Fec'estrien P;etect[on � � J � ��� � 5Ge p:�rporF of sale!.
1(Fenca)(Canopy) i ' � ,_ 1,os o�vner ef tFe properiy,am exdusively comror
ting with licensed com^oclors to con;hucf ihe project(Sec.
!Spetial Inspection � I � � - 7044)BusF�xess a�d Professioxs Code:The Contractor's
I!Conc.j{hAesortryjjVJelding)� � ---- , Lecertselau�dnesnotapylyu�¢unwrserofprop¢rtymbr.
J btti?ds nr impror�s d�ereon,und wbo contr¢cts for suc!
L- ro ects w£86 a coniracto s licensed
Loi Drainog=� � p J 9'O pur.cuand to Lbe
Contractor's T itense L¢wJ.
?arkin§ � i j � .,_,.._,�._.__,,. � .
, �„__ I J_ ` ` � � I am exempt under Sec ,B.&P.C.for 4his
� .�_�^ .�., : ! � . � reason_
� � - � Qate Owner �
i-- �,a,.�__��..��.:.�...�. .�
�r.a.-a:•.a7s -n . ,�e:.c:'s r,.v:::oaee � -�._. a..-�.��____....�.-..a�.�
� J_ . .' � ���s��Ifd�P�CTO�'S ld.�i E'S
�Locciion- � i T� � -'-_� s _......m...,..d�.s.«.a..,,,-�o.,,....-........,-..�.�.-.-�.�u.,d-.y..+m..
Fo�(Setbeck�1'ardsJ _�_�--V..- +� 'a
ns�—� � � . , . . .
5!ab _'.��__.—�
/� �---�._
FrQme IC'�^7/�� � ,/i�l',-D,i .
�L I
=nAr,�:nsu;ation � l�7�—� "- i
.�� �/�j;'��7��',.a�'�--`.� �
Lath/Drywnll- / � E '
Intaricr ���,�.i./ �t.��__�_
Lcih-E>,erior �f ;��„/>(,s�.��—,,___� .
__r �� �
Hcuse Number-- � f € �
C rrec:&9csted j____, �-�_ � I
Flncl- � '_�-__.._ �._—__� _
En'c-r cn Front�,_`�._,�� � „_
�.''�'�.e�tJ � ��� 3�t%Z .�
_, 2�„_��
' --- � �
�.._�.��_,_..—._ ---- --- -�-;--------
��� "' �,-- iC _
_
� _�'� �"a'��.__��G7�.��'oZ��-�?-�!�:�....j��s
-- r�